[Misuse and dependence on prescription opioids: Prevention, identification and treatment]

In vivo effects of a selected thiourea derivative 1-(2-chlorobenzoyl)-3-(2,3-dichlorophenyl) against nociception, inflammation and gastric ulcerogenicity: Biochemical, histopathological and in silico approaches

The current study was designed to investigate the potential of a synthetic therapeutic agent for better management of pain and inflammation, exhibiting minimal to non-existent ulcerogenic effects. The effect of 1-(2-chlorobenzoyl)-3-(2,3-dichlorophenyl) thiourea was assessed through model systems of nociception and anti-inflammatory activities in mice. In addition, the ulcerogenic potential was evaluated in rats using the NSAID-induced pyloric ligation model, followed by histopathological and biochemical analysis. The test was conducted on eight groups of albino rats, comprising of group I (normal saline), groups II and III (aspirin® at doses of 100 mg/kg and 150 mg/kg, respectively), groups IV and V (indomethacin at doses of 100 mg/kg and 150 mg/kg, respectively), and groups VI, VII, and VIII (lead-compound at 15 mg/kg, 30 mg/kg and 45 mg/kg doses, respectively). Furthermore, molecular docking analyses were performed to predict potential molecular target site interactions. The results showed that the lead-compound, administered at doses of 15, 30, and 45 mg/kg, yielded significant reductions in chemically and thermally induced nociceptive pain, aligning with the levels observed for aspirin® and tramadol. The compound also effectively suppressed inflammatory response in the carrageenan-induced paw edema model. As for the ulcerogenic effects, the compound groups displayed no considerable alterations compared to the aspirin® and indomethacin groups, which displayed substantial increases in ulcer scores, total acidity, free acidity, and gastric juice volume, and a decrease in gastric juice pH. In conclusion, these findings suggest that our test compound exhibits potent antinociceptive, anti-inflammatory properties and is devoid of ulcerogenic effects.

Opioid misuse in community pharmacy patients with chronic non-cancer pain

AIMS

Community pharmacists could contribute to identify people misusing prescription opioids, which may be associated with hospitalizations, substance use disorders and death. This study investigated prescription opioid misuse in community pharmacy patients and the factors potentially associated with high Prescription Opioid Misuse Index (POMI) scores.

METHODS

In this cross-sectional study, pharmacy students asked patients with opioid prescriptions to fill in a questionnaire (including the POMI) in community pharmacies in a French region, in April 2019. Eligible patients were adults with chronic non-cancer pain who consented to participate.

RESULTS

In total, 414 patients (62.4% women; mean age: 58.00 years ± 16.00) were included. The prescribed opioids were mainly weak opioids (73.2%; paracetamol/tramadol: 35%). Strong opioids (32.6%) included oxycodone (11.95%), fentanyl (9%) and morphine (9%). The median morphine milligram equivalent (MME) was 40 mg/day (IQR_25-75 : 20-80). The POMI score (0 to 6) was ≥4 in 16% of patients who were younger (P < .01), more urban (P = .03), with higher pain visual analogue scale (VAS) score (P < .01) and MME (P < .01), and treated more frequently with strong opioids (P = .04). In multivariate analysis, age (OR_{for 10y} : 0.68 (95% CI: 0.56-0.82, P < .0001)), VAS (OR_2units : 1.78 (95% CI: 1.26-2.40, P = .0008)), and MME (>100 mg, OR: 2.65 (95% CI: 1.14-4.41, P = .0194)) were significantly associated with POMI scores ≥4.

CONCLUSIONS

The high proportion of patients with high POMI scores underlines the interest of prescription opioid misuse screening in community pharmacies, in order to help these patients and refer them to pain specialists, if needed.

Analgesic Opioid Misuse and Opioid Use Disorder among Patients with Chronic Non-Cancer Pain and Prescribed Opioids in a Pain Centre in France

(1) Background: Chronic non-cancer pain (CNCP) remains a public health challenge around the world. Opioids (PO) have been increasingly used in the treatment of CNCP in the last 20 years. This study aimed to assess the prevalence of opioid misuse and prescribed-opioid use disorder (p-OUD) among patients with CNCP in a pain centre in France, and to analyse risk factors for moderate or severe p-OUD. (2) Method: A cross-sectional study was conducted, including patients consulting for pain management in the pain centre of Brest University Hospital. A self-questionnaire was administered (sociodemographic data, medical data, PO misuse, and p-OUD according the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) criteria). Descriptive, univariate, and multivariate analyses were conducted, together with a principal component analysis, in order to identify factors associated with p-OUD. (3) Results: In total, 115 patients were included, the majority of whom were women, with a mean age of 52 years old [18–82]; 64.3% (n = 74) had a current prescription for opioid analgesics (weak or strong). In this group, 56.7% (n = 42) had no or only mild p-OUD and 43.3% (n = 32) had current moderate or severe p-OUD. Patients with moderate or severe p-OUD were more likely to have a current antidepressant prescription, to have had psychotherapy, to currently use strong opioids and oxycodone, and to report taking more frequent doses than prescribed and feeling dependent. (4) Conclusions: We showed that the prevalence of current moderate/severe p-OUD concerned 43.3% of the patients with a CNCP seeking treatment in a pain centre. According to these results, several measures are relevant in managing p-OUD among patients with CNCP.

Acute pain management among patients with opioid maintenance therapy: specificities and difficulties identified in primary care: a qualitative study

OBJECTIVES

In the last 30 years, opioid maintenance treatment prescription (OMT) has changed patients' and also changed physicians' practices. General practitioners (GPs) have to deal with patients on OMT who are in acute pain. The objective of this qualitative study was to explore medical care challenges and solutions identified by GPs in the management of acute pain among patients receiving OMT.

DESIGN AND SETTING

Qualitative study with semistructured interviews were used as a data collection technique with a sampling strategy using a snowball sampling method to obtain a purposive sample of practicing GPs. Analysis was undertaken using a thematic analysis method.

PARTICIPANTS

Twelve GPs, working in France (Brittany) who prescribe OMT were interviewed.

RESULTS

The thematic analysis resulted in two main themes relating to specificities and difficulties identified: (1) Medical care and training challenges identified by GPs treating patients on OMT with acute pain, with four subthemes : management of these situations not concerning primary care, lack of training prompts GPs to rely on peer and specialist support, lack of guidelines and conflicting recommendations between clinicians in different settings (2) linked to the patient-GP relationship, with six subthemes: Implementing an individualised centred approach, acute pain management during OMT relies on a relationship based on trust, GPs found difficulties in evaluating and treating pain, difficulties in care adherence, fear of patients destabilisation, fear of misuse and diversion.

CONCLUSION

The complexity of acute pain and OMT entails significant challenges for clinicians and patients. In primary care, it is hard to achieve a balance between pain relief and opioid use disorder treatment, in a global patient-centred approach. Fear of misuse or diversion was not a important factor, except for patients not known to the practitioners, but GPs were concerned with the risks of patient destabilisation in situations of acute pain.

Les opioïdes : de la douleur à l’addiction ?

La crise des opioïdes actuelle aux États-Unis et sa médiatisation soulèvent la question de l’utilisation adéquate de ces antalgiques dans notre pratique quotidienne. En quatre vignettes cliniques, nous évoquons le travail conjoint des équipes d’addictologie et d’algologie pour prendre en charge au mieux les patients sous opioïdes en oncologie. Nous présentons les meilleurs moyens de diagnostiquer, prévenir et prendre en charge les écueils de ces traitements : la dépendance aux opioïdes de prescription et le mésusage des opioïdes de prescription, voire l’addiction aux opioïdes. Une des clés de cette prise en charge est la multidisciplinarité, centrale dans la réunion de concertation pluridisciplinaire.

Medicine misuse: A systematic review and proposed hierarchical terminology

AIMS

Although medicine misuse is a public health issue, it has multiple meanings in the medical literature. This study aimed to characterize, classify and identify the most appropriate definitions of medicine misuse.

METHODS

A systematic review was performed in Medline, ISI Web of Science, SocINDEX, PsycInfo, PsycArticles and Psychological and Behavioral Sciences Collection, using keywords related to "misuse", "appropriateness" and "medicine" between 1 November 2008 and 25 August 2020. Additional searches were conducted in websites of regulatory agencies and public health institutions. Two authors independently selected studies providing both definitions and examples of misuse, while a third resolved disagreements. Definitions were used to propose a hierarchical classification based on initiator, intent, purpose and context of medicine misuse. The study is registered on PROSPERO: CRD42018115789.

RESULTS

Of 3404 identified records, 51 were included. A total of 71 definitions and 74 examples of misuse were retrieved. When the prescriber is initiator and according to intent, potential medicine misuse referred to "intentional or unintentional prescribing not in line with clinical evidence". Based on context, they could prescribe medicines not clinically justified, i.e. overprescribing, or prescribe indicated medicines incorrectly, i.e. misprescribing. Among other groups of definitions, those overlapping with drug abuse or medication use errors were considered out-of-scope.

CONCLUSION

This systematic review provides a comprehensive overview of the terms and definitions used to characterize medicine misuse and could serve as a basis for a terminology that makes clear distinctions between misuse, abuse and errors.

[Prolonged-release buprenorphine formulations: Perspectives for clinical practice]

Buprenorphine and methadone are the two main opioids agonist treatments approved for opioid use disorder. Buprenorphine is a partial agonist of the mu-opioid receptors, which has been merely available through sublingual form until now. In practice, the use of buprenorphine is smoother than that of methadone, and it induces reduced risks of overdose. However, sublingual buprenorphine also exposes to risks (e.g., withdrawal, misuse) and constraints (e.g., daily intake). Three new galenic formulations of prolonged-release buprenorphine (PRB) are being commercialized and should allow some improvements in patients' comfort and safety. This narrative review aims to describe the main technical features and efficacy and safety data of these PRBs, as well as patients' and professionals' expectancies and concerns, using data of the scientific literature and the regulatory texts. PRBs consist of one subcutaneous implant and two subcutaneous injection depots. Sixmo®/Probuphine® is a six-month-long implant which needs to be surgically placed and removed and is approved for subjects previously treated with a maximum daily dose of 8mg of sublingual buprenorphine, and can be used only for two successive periods of six months before the subject needs to be switched back to sublingual form. Sublocade® is a one-month-long depot formulation that is indicated in switch from sublingual buprenorphine, and which proposes only two dose schemes, i.e., 100 and 300mg monthly. Buvidal®/Brixadi® is a one-week- or one-month-long depot formulation with multiple dosages, which can be used in initiation or in switched from sublingual formulations. While opioid users report some concerns with a risk of coercive use of long-acting forms of buprenorphine, both users and professionals deem that these new specialties could be particularly appreciated in stabilized patients bothered with the daily intake of the treatments, or specific situations at risk of treatment dropout (e.g., following hospital discharge or prison release).

Prolonged-release buprenorphine formulations: Perspectives for clinical practice

Buprenorphine and methadone are the two main opioid agonist treatments approved for opioid use disorder. Buprenorphine is a partial agonist of the mu opioid receptors, which has been merely available through sublingual form until now. In practice, the use of buprenorphine is smoother than that of methadone, and it induces reduced risks of overdose. However, sublingual buprenorphine also exposes to risks (e.g., withdrawal, misuse) and constraints (e.g., daily intake). Three new galenic formulations of prolonged-release buprenorphine (PRB) are being commercialized and should allow some improvements in patients' comfort and safety. This narrative review aims to describe the main technical features and efficacy and safety data of these PRBs, as well as patients' and professionals' expectancies and concerns, using data of the scientific literature and the regulatory texts. PRBs consist of one subcutaneous implant and two subcutaneous injection depots. Sixmo®/Probuphine® is a six-month-long implant which needs to be surgically placed and removed and is approved for subjects previously treated with a maximum daily dose of 8mg of sublingual buprenorphine, and can be used only for two successive periods of six months before the subject needs to be switched back to sublingual form. Sublocade® is a one-month-long depot formulation that is indicated in switch from sublingual buprenorphine, and which proposes only two dose schemes, i.e., 100 and 300mg monthly. Buvidal®/Brixadi® is a one-week- or one-month-long depot formulation with multiple dosages, which can be used in initiation or in switched from sublingual formulations. While opioid users report some concerns with a risk of coercive use of long-acting forms of buprenorphine, both users and professionals deem that these new specialties could be particularly appreciated in stabilized patients bothered with the daily intake of the treatments, or specific situations at risk of treatment dropout (e.g., following hospital discharge or prison release).

Trends in hospital consumption of analgesics after the implementation of a pain performance improvement plan

Background

Pain management committee established a pain performance improvement plan in 2012.

Objectives

The aim of the study was to assess the trends in analgesic consumption in a tertiary teaching hospital and the associated economic impact.

Methods

A descriptive, retrospective study was conducted between 2011 and 2015. The analysis included: anti-inflammatory and antirheumatic products non-steroids, opioid analgesics and other analgesics and antipyretics. Data are converted into DDD/100 bed-days to analyze consumption trends. Main outcome measure: assessment of the analgesic consumption after the implementation of a pain performance improvement plan.

Results

Overall, non-steroidal anti-inflammatory and antirheumatic products consumption decreased in 24.8 DDD/100 bed-days (−28.3%), accounting for most of the total analgesic consumption decrease (−13%) and total cost (−44.3%). Opioid consumption increased markedly from 22.3 DDD/100 bed-days in 2011 to 26.5 DDD/100 bed-days in 2015 (+18.9%). In 2011, the most consumed opioid was morphine (8.6 DDD/100 bed-days). However, there was an increasing trend in fentanyl consumption (from 8.1 to 12.1 DDD/100 bed-days in 2015), which resulted in fentanyl replacing morphine from the most consumed opioid in 2015 (12.1 DDD/100 bed-days). In 2015, the group of other analgesics and antipyretics represented 46.2% of the total analgesic consumption. Acetaminophen was the most commonly consumed analgesic drug (53.2 DDD/100 bed-days in 2015) and had the highest total cost, it represented 55.4% of the overall cost in 2015.

Conclusion

Opioid consumption showed an increasing trend during the 5 year period, with fentanyl replacing morphine as the most used opioid. In general, analgesics diminished use was due to the decreasing trend of consumption of non-steroidal anti-inflammatory and antirheumatic products.

[Trends in hospital consumption of analgesics after the implementation of a pain performance improvement plan]

BACKGROUND

Pain management committee established a pain performance improvement plan in 2012.

OBJECTIVE

The aim of the study was to assess the trends in analgesic consumption in a tertiary teaching hospital and the associated economic impact.

METHODS

A descriptive, retrospective study was conducted between 2011 and 2015. The analysis included: anti-inflammatory and antirheumatic products non-steroids, opioid analgesics and other analgesics and antipyretics. Data are converted into DDD/100 bed-days to analyze consumption trends.

MAIN OUTCOME MEASURE

assessment of the analgesic consumption after the implementation of a pain performance improvement plan.

RESULTS

Overall, non-steroidal anti-inflammatory and antirheumatic products consumption decreased in 24.8 DDD/100 bed-days (-28.3%), accounting for most of the total analgesic consumption decrease (-13%) and total cost (-44.3%). Opioid consumption increased markedly from 22.3 DDD/100 bed-days in 2011 to 26.5 DDD/100 bed-days in 2015 (+18.9%). In 2011, the most consumed opioid was morphine (8.6 DDD/100 bed-days). However, there was an increasing trend in fentanyl consumption (from 8.1 to 12.1 DDD/100 bed-days in 2015), which resulted in fentanyl replacing morphine from the most consumed opioid in 2015 (12.1 DDD/100 bed-days). In 2015, the group of other analgesics and antipyretics represented 46.2% of the total analgesic consumption. Acetaminophen was the most commonly consumed analgesic drug (53.2 DDD/100 bed-days in 2015) and had the highest total cost, it represented 55.4% of the overall cost in 2015.

CONCLUSION

Opioid consumption showed an increasing trend during the 5 year period, with fentanyl replacing morphine as the most used opioid. In general, analgesics diminished use was due to the decreasing trend of consumption of non-steroidal anti-inflammatory and antirheumatic products.